Archive for August, 2017

The World Health Organisation’s (WHO) guidelines range from specific interventions targeting emerging health issues to general public health guidance. In 2007, WHO established the Guidelines Review Committee (GRC) to ensure that WHO guidelines meet the highest international standards and contain trustworthy and implementable recommendations. While the GRC played a positive role in the quality control of guidelines, these were often too long and technical, dissemination needed to improve and more products were needed for targeted audiences among other concerns such as issuing recommendations despite low-quality evidence,

A recent WHO evaluation concluded that although the GRC played a positive role in quality control of guidelines, the guidelines were often too long and technical, distribution needed to improve, and more derivative products are needed for specific audiences. Other identified concerns include issuance of strong recommendations despite low-quality evidence, suboptimal use of evidence in developing recommendations, insufficient diversity among guideline development group members, and incomplete adherence to WHO’s conflict of interest policy.

The production of high-quality guidelines is challenging for any organisation. WHO faces additional challenges having to adapt global recommendations to a local setting, which requires derivative products such as implementation tools or how-to manuals to ensure uptake. WHO Collaborating Centres, of which there are over 700 globally, play a crucial role in supporting guideline development; however, confusion arises when Collaborating Centres publish advice that is interpreted as being issued by WHO when this is not the case. Development of guidelines for emergency settings is particularly challenging because of time constraints and the evidence to inform future actions is often insufficient, particularly in the context of evolving or emerging public health threats. Finally, the framework underpinning guideline development at WHO—the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)—was initially developed for clinical interventions, and although GRADE can be successfully applied to the development of guidelines in public health, there are numerous challenges, such as the formulation of recommendations on complex interventions, use of non-traditional types of data (eg, big data), and hazard identification.

Several steps would improve the quality of guidelines issued by WHO. First, WHO needs to put the necessary resources, both monetary and staff time, into producing trustworthy and effective guidelines. Second, WHO needs to promote and support evaluations of its guidelines to ensure an ongoing cycle of quality improvement. Third, collaboration needs to be augmented both within WHO and with external partners so that common challenges are discussed and solutions shared. Fourth, clear processes and methods for guideline development in the context of emergencies are needed to help to ensure valid recommendations and optimal transparency and usability, regardless of the development timeframe. Finally, guideline development must be receptive to the needs of end users. Guidelines need to be succinct and written for the target audience, while still describing transparent methods. Tools for guideline implementation, adaptation, and updating need to be planned from the beginning of each guideline development process, and not treated as afterthoughts.

WHO looks forward to its next 10 years of guideline development, meeting the substantial challenges head on, while continuing to self-reflect, evaluate, learn, and evolve. In an increasingly crowded arena of global health, WHO will work to ensure that its guidelines remain a trustworthy source of relevant, usable, and impactful normative guidance for Member States and the global public health community.

A Stuttgart judge has ruled that retrofitting illegally polluting diesel vehicles will not solve the German region’s air quality crisis and demanded a diesel ban be implemented in the city from January 2018.

The ruling means Stuttgart’s government must rewrite its Air Quality Plan (AQP), as the current version is inadequate and will not protect people’s health in the shortest time possible.

Air quality in the region is illegally poor, regularly breaching limits for toxic gas nitrogen dioxide (NO2) and dangerous coarse particles (PM10). The levels are some of the worst in Germany.

Stuttgart’s local government came up with a draft Air Quality Plan in response to legal action launched by environmental lawyers ClientEarth and German charity Deutsche Umwelthilfe (DUH).

The draft plan contained some positive measures – including a reactive ‘peak pollution’ diesel ban – but was not adequate to tackle Stuttgart’s air pollution, in the charities’ view. Shortly before the hearing, Stuttgart’s authorities tried to take a step back and avoid diesel bans, relying on the car industry’s proposals to retrofit older “Euro 5” diesel models.

But the judge agreed with ClientEarth and DUH that it was insufficient and ruled that restricting access to the most polluting diesel vehicles is unavoidable to protect the health of people living and working in Stuttgart.

ClientEarth clean air lawyer Ugo Taddei said: “Hot on the heels of Dusseldorf and Munich, now Stuttgart too has been ordered by a court to introduce restrictions on the most polluting diesel vehicles. In striking contrast to reluctant governments and a discredited car industry, courts across Europe are stepping in to protect people’s right to clean air and to impose effective measures that will put a definitive end to this public health crisis.

“The judge has clarified that a diesel ban is unavoidable. Stuttgart’s authorities must now find rapid and effective ways to solve the region’s air quality issues. This should include a more structured approach that acknowledges the emissions issues with diesel vehicles – it must also not put undue confidence in what retrofitting can achieve.”

Lawyer Remo Klinger, who represented the NGOs in the case, said: “The court saw through the bluster of the Stuttgart authorities’ plan, posing critical questions and dismissing the arguments. We now have a reinforced decision that says diesel bans are the way forward and actionable as of today. This goes even further than the progressive decision by Düsseldorf in September – diesel bans are not just permitted in certain streets: they can be implemented for the whole low emission zone.”

Debate around diesel bans is ongoing in Germany, which is home to many global automotive heavyweights. Most recently, Munich’s mayor announced he would implement a diesel ban, on the basis that he could see “no other way” to bring alarming air pollution levels in the region down as quickly as possible.

A decision is due this autumn from the German Federal Administrative Court, which will determine whether cities have the power to ban diesel vehicles or the federal government must decide.

Stuttgart’s authorities must now introduce restrictions on diesel vehicles from January 2018 to tackle the public health emergency facing the city.